The Future of the American Mind (Hint: Nurse Ratched Wins)
Marcia Angell’s second part in her analysis of drugged-up American psychiatry, “The Illusions of Psychiatry ,” has appeared in the July 14 issue of the New York Review of Books (I discussed the first here ). The banner across the cover reads “THE CRAZY STATE OF PSYCHIATRY.”
This second article is less exciting than the first—pedestrian really—as it traces the history of biological psychiatry and its leading proponents, aided and abetted by the pharmaceutical industry, particularly in terms of the development of the DSMs, edition three through the currently planned edition five. This history is replete with conflicts of interest, since psychiatry is the medical speciality best funded by the industry.
By fully embracing the biological model of mental illness and the use of psychoactive drugs to treat it, psychiatry was able to relegate other mental health care providers to ancillary positions and also to identify itself as a scientific discipline along with the rest of the medical profession. Most important, by emphasizing drug treatment, psychiatry became the darling of the pharmaceutical industry, which soon made its gratitude tangible. . . .
Of the 170 contributors to the current version of the DSM (the DSM-IV-TR), almost all of whom would be described as KOLs [key opinion leaders], 95 had financial ties to drug companies, including all of the contributors to the sections on mood disorders and schizophrenia.
[Angell nowhere notes or discusses addiction in DSM-5 and the brain disease model espoused by the chair of the addiction subcommittee, psychiartrist Charles O’Brien, in league with National Institute on Drug Abuse director Nora Volkow.]
Angell points to the expanding diagnostic categories in each edition of the DSM, and the way in which ordinary behaviors, often outgrown, have become psychiatric symptoms. Ho-hum. Nothing Angell says will be surprising to readers of PT blogs—it’s all been said here, indeed by some of the leading critics Angell cites in the NYRB.
Here are the concluding paragraphs of the article:
At the very least, we need to stop thinking of psychoactive drugs as the best, and often the only, treatment for mental illness or emotional distress. Both psychotherapy and exercise have been shown to be as effective as drugs for depression, and their effects are longer-lasting, but unfortunately, there is no industry to push these alternatives and Americans have come to believe that pills must be more potent. More research is needed to study alternatives to psychoactive drugs, and the results should be included in medical education.
In particular, we need to rethink the care of troubled children. Here the problem is often troubled families in troubled circumstances. Treatment directed at these environmental conditions—such as one-on-one tutoring to help parents cope or after-school centers for the children—should be studied and compared with drug treatment. In the long run, such alternatives would probably be less expensive. Our reliance on psychoactive drugs, seemingly for all of life’s discontents, tends to close off other options. In view of the risks and questionable long-term effectiveness of drugs, we need to do better. Above all, we should remember the time-honored medical dictum: first, do no harm (primum non nocere).
Of course, these pleas, since they are based on well-known information and common criticisms of the biological psychiatric establishment, will have zero effect. Actually, that’s the point of Angell’s series, that the system is so well-ensconced as to be inured to criticism—beyond redemption, really. Consider these observations (Carlat is practicing psychiatrist Daniel Carlat, author of Unhinged: The Trouble with Psychiatry—A Doctor’s Revelations About a Profession in Crisis
The drug industry, of course, supports other specialists and professional societies, too, but Carlat asks, “Why do psychiatrists consistently lead the pack of specialties when it comes to taking money from drug companies?” His answer: “Our diagnoses are subjective and expandable, and we have few rational reasons for choosing one treatment over another.” Unlike the conditions treated in most other branches of medicine, there are no objective signs or tests for mental illness—no lab data or MRI findings—and the boundaries between normal and abnormal are often unclear. . . .
This matching exercise [that Carlat performs with DSM categories], he writes, provides “the illusion that we understand our patients when all we are doing is assigning them labels.” Often patients meet criteria for more than one diagnosis, because there is overlap in symptoms. For example, difficulty concentrating is a criterion for more than one disorder. One of Carlat’s patients ended up with seven separate diagnoses. “We target discrete symptoms with treatments, and other drugs are piled on top to treat side effects.” A typical patient, he says, might be taking Celexa for depression, Ativan for anxiety, Ambien for insomnia, Provigil for fatigue (a side effect of Celexa), and Viagra for impotence (another side effect of Celexa).
As for the medications themselves, Carlat writes that “there are only a handful of umbrella categories of psychotropic drugs,” within which the drugs are not very different from one another. He doesn’t believe there is much basis for choosing among them. “To a remarkable degree, our choice of medications is subjective, even random. Perhaps your psychiatrist is in a Lexapro mood this morning, because he was just visited by an attractive Lexapro drug rep.”
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The apparent prevalence of “juvenile bipolar disorder” jumped 40-fold between 1993 and 2004, and that of “autism” increased from one in five hundred children to one in 90 over the same decade. Ten percent of 10-year-old boys now take daily stimulants for ADHD—”attention deficit/hyperactivity disorder”—and 500,000 children take antipsychotic drugs. . . .
[A] Rutgers University study found that children from low-income families are four times as likely as privately insured children to receive antipsychotic medicines.
Angell begins her conclusion with the phrase, “At the very least.” Okay, well enough said. But if the leading popular intellectual periodical in America won’t go beyond figuring out “the very least” we can think and do, then to whom do we turn to learn where this train is finally headed?
There are two primary areas about which to wonder: the psychiatric juggernaut—ahem, I mean profession—and the American mind.
With more and more illness categories, more and more diagnoses, and in fact more and more psychiatrically designated sick people, where are we headed? Psychiatry has gotten Americans used to the idea that they and their children suffer from mental illnesses from which they can never fully be reclaimed; we are already at the half-way mark (almost half of Americans now qualify for at least one major psychiatric diagnosis at some point) and this prevalence continues growing unabated.
So, what do we think of ourselves? That we are inherently flawed (like the Good Book says)? That we must turn to and rely on psychiatry and drug companies as our only hope for (partial) redemption, with the demons always needing to be staved off? That raising chldren is a matter of zeroing in on their appropriate diagnoses? That our contentment (not quite happiness) depends on finding our own appropriate psychiatric condition?
Is there any point at which so many people are ill, and none ever fully recovers, that we get off this train?
There are no such terminals on the horizon.